What the DSM-5 Says About BFRBs

When it comes to mental health disorders, the Diagnostic and Statistical Manual of Mental
Disorders (DSM, in this case the DSM-5) is an important part of diagnosing for medical professionals. We especially talk a lot about it in the BFRB community because of this edition’s addition of dermatillomania (listed as Excoriation (Skin Picking) Disorder) and because of the re-categorization of all BFRBs. Formerly a part of the Impulse Control Disorder section, trichotillomania, dermatillomania and all BFRBs are now nestled in among obsessive-compulsive and related disorders.

At CBSN, we decided to take a look at what the DSM-5 says about BFRBs and their categorization. Below are summaries of the information found within the DSM-5, starting with the overall category of obsessive-compulsive and related disorders, then moving on to trichotillomania, excoriation (skin-picking) disorder, and finally body-focused repetitive behaviours.

Obsessive-Compulsive and Related Disorders

Firstly, here is the list of what falls into this category: obsessive-compulsive disorder, body dysmorphic disorder, hoarding, trichotillomania, excoriation (skin picking) disorder, substance/medication-induced obsessive-compulsive and related disorder, obsessive-compulsive and related disorder due to another medical condition, other specified obsessive-compulsive and related disorder, and unspecified obsessive-compulsive and related disorder.

That’s a pretty big list and it’s a wonder BFRBs fit in there at all. However, the DSM-5 doesn’t try to lump it in as being the exact same as what people typically think of obsessive compulsive disorders. Indeed, we see from this categorization that BFRBs are not obsessive compulsive disorders, but are instead only related to them.

It acknowledges BFRBs as unique when it says, “Other obsessive-compulsive and related disorders are characterized primarily by recurrent body-focused repetitive behaviors (e.g., hair pulling, skin picking) and repeated attempts to decrease or stop the behaviors.” While other obsessive-compulsive behaviors can have a bodily component, like hand washing, the DSM-5 recognizes that those behaviours are not stemming from a focus on the body and have other factors that incite the behaviour. Specifically mentioning BFRBs sets trichotillomania, dermatillomania and other behaviours like those apart from traditional OCD.

The DSM-5 even states that “there are important differences in diagnostic validators and treatment approaches across these disorders,” which is important for the editors to include because while BFRBs are officially under the OCD spectrum, they don’t work exactly the same way and thus won’t react the same to treatments.

One of the criticisms of having dermatillomania and other BFRBs added to the DSM-5 was that it was just making common behaviours into a problem. And for those that worry along the same lines about these disorders being over-diagnosed or having a diagnosis for them placed on people who participate in normal grooming behaviours—a.k.a. the casual pull of a stray hair or pop of a pimple—the DSM-5 covers that in the introduction to OCD and related disorders as well.

Summing that up, it says, yes, people pull and pick, but these disorders go far beyond that.

Trichotillomania (Hair Pulling Disorder)

Diagnostic Criteria

Recurrent pulling out of one’s hair, resulting in hair loss.

Repeated attempts to decrease or stop hair pulling.

The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition).

The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).

The DSM-5 recognizes that hair pulling can occur from any part of the body, with the head, eyebrows and eyelids being the most common pull sites. It talks about how some people pull for long sessions, whereas others pull in a more scattered way throughout the day. In that sense, it recognizes the diversity of the disorder and that different people pull in different ways, which is important because so many people compare themselves to other pullers to determine how severe their disorder is or something of that sort. The pulling doesn’t have to look the same in everyone though in order for it to be trich and in order for it to be impactful on your life.

That being said, the DSM-5 also gives a clear difference between what the disorder is and is not. It makes mention of a negative impact, resulting in feelings of “loss of control, embarassment, and shame,” and later specifies that trichotillomania is not hair removal of any sort that is done purely cosmetically. If someone bites his or her hair, that is also different from trichotillomania. This clearly separates hair pulling from common hair pulling that everyone might do every once in a while when they pull out a stray hair or pluck their eyebrows to shape them. It sets pullers apart and can narrow it down to the 1-2% statistic that the DSM-5 has found.

While the fact that the pulling isn’t solely for cosmetic reasons is specified, the fact that there are ritualistic behaviours is not ignored. The searching for particular hairs, the specific ways in which a hair might be pulled, and even examining the hair in different ways and putting the hair in the mouth are highlighted as common pulling behaviours. It outlines how all behaviours concerning trich can be triggered by a range of emotions (from anxiety to boredom), can include tension beforehand and tends to lead to some form of release or pleasure immediately afterwards. But through all of this, there is usually no physical pain.

Interestingly, the DSM-5 mentions other behaviours such as pulling from other people and also from pets, dolls, and other materials or objects that satisfy the same need.

Another question that is often asked is age of onset. According to the DSM-5, and other sources often agree, pulling most commonly starts around puberty. Pulling can of course start earlier, but their sources show that when pulling starts in younger children, in particular infants, the child will outgrow it. When pulling starts that young, it is often a self-soothing strategy, much like thumb sucking, which the child will stop doing once it’s no longer needed. (Not to say that is how all cases will turn out, but keep in mind, despite its specificities, the DSM-5 is still speaking in general, broad tones.)

And once it starts, “[t]he usual course of trichotillomania is chronic with some waxing and waning if the disorder is untreated,” and it reiterates and elaborates by saying “[f]or some individuals the disorder may come and go for weeks, months, or years at a time.” What that means is without treatment, the disorder will be persistent, but it will have periods when it’s really strong and other times when it’s barely a problem, if a problem at all. It is CBSN’s opinion that even with treatment there is still the potential for waxing and waning, but treatment provides a person with more tools with which to cope and deal with these behaviours.

For all you women out there: “Symptoms may possibly worsen in females accompanying hormonal changes.” That’s right, you’re not imagining it. ‘That time of the month’ and other hormonal challenges that women face can set you off kilter and put a dent into your efforts.

There is evidence saying there is a genetic component, and that evidence also suggests that people with first degree relatives (mother, father, siblings, children) who have obsessive compulsive disorder are more likely to have trichotillomania. That being said, those with trich are at high risk for having other mental health issues, in particular “major depressive disorder and excoriation (skin-picking) disorder.” This risk is called co-morbidity.

The DSM-5 mentions that when it comes to damage to the hair, in terms of its re-growth and how healthy it is, there is potential for it to be irreversible. When it comes to how the body itself may suffer, there is a list, some of which we had to look up the definition for. It says these are “infrequent,” but here they are:

digit purpura (purplish discolouration of the skin cause by hemorrhaging)

If you also have trichophagia (eating of the hair), one of the main risks for that is trichobezoars (hairballs), which can cause additionally:

anemia (decrease of red blood cells)

abdominal pain

hematemesis (vomiting blood)

nausea/vomiting

bowel abstruction

perforation

Excoriation (Skin-Picking) Disorder

Dermatillomania

Skin Picking Disorder

Chronic Skin Picking

Compulsive Skin Picking

Neurotic Excoriation

Acne Excoriee

Pathological Skin Picking

Pyschogenic Excoriation

All these different names for one disorder, and the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, brought on yet another, calling it Excoriation (Skin-Picking) Disorder. Although it’s not defined in the DSM-5, we wanted to first highlight what excoriation or to excoriate, means.

Most online definitions we found point to it meaning that skin is worn away, such as by chafing, but we have also found definitions that talk about tearing the skin away and even flaying. We wonder if these imprecise and scattered definitions of the word are why the editors of the DSM-5 chose to call it Excoriation (Skin-Picking) Disorder as opposed to simply Excoriation Disorder.

Whatever the reason or reasons for choosing this name for what the community typically calls dermatillomania, this is 2013, when the DSM-5 was published, was the first time the behaviour was recognized as a legitimate disorder.

To begin, here is the outlined Diagnostic Criteria for Excoriation (Skin-Picking) Disorder:

Recurrent skin picking resulting in skin lesions.

Repeated attempts to decrease or stop skin picking.

The skin picking causes clinically significant distress or impairment in social, occupation, or other important areas of functioning.

The skin picking is not attributable to the psychological effects of a substance (e.g., cocaine) or another medical condition (e.g., scabies).

The skin picking is not better explained by symptoms of another mental disorder (e.g., delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body-dysmorphic disorder, stereotypes in stereotypic movement disorder, or intention to harm oneself in non-suicidal self-injury).

Considering how many pickers are often judged as being drug users, it’s both a great and important that the DSM-5 acknowledges and emphasizes that the picking and the disorder as a whole are separate from drug use and is not drug induced. Equally important is for it to acknowledge that the disorder is not Body-Dysmorphic Disorder, although the difference is still a little muddy (in our opinion) based off of the part 5 description alone.

According to the DSM-5, about 1.4% (“or somewhat higher”) of people have this disorder, with the vast majority being female. Excoriation disorder spans across many ages, with the most common starting point being puberty, which is likely because of acne or another skin condition. The face, arms and hands are often the go-to areas for pickers, but the DSM-5 does also note that picking can occur anywhere on the body.

The targets for skin pickers include healthy skin, minor imperfections, pimples, callouses and old picking scabs, which can be picked at with fingernails (most common) or even tools like tweezers or pins. Picking can occur in short spurts throughout the day or for prolonged sessions.

Like with others BFRBs, there is a ritualistic nature to skin picking. Some have particular kinds of scabs that they search for to pick and after picking, some “examine, play with, or mouth or swallow the skin.” Some people even pick the skin of other people.

Overall, picking can be focused or automatic—meaning that sometimes it is a conscious effort whereas other times it is more absent-minded—and sometimes people have a mix of both types of behaviours.

The DSM-5 says that the picking is typically “preceded or accompanied by various emotions states,” such as anxiety or boredom. There is also a sense of tension that can be felt before, during or while resisting picking, which is often alleviated after the picking. “[G]ratification, pleasure, or a sense of relief” are within the possible range of emotions after the behaviour has been completed. Like with trichotillomania, pickers can feel distress such as “loss of control, embarrassment, and shame.”

The majority of consequences that the DSM-5 talks about are functional, meaning the effect on a person’s everyday life. People avoid social situations, public situations and many times even work or school. However, there are medical consequences too, such as “tissue damage, scarring, and infection and [it] can be life threatening.” Infections frequently require “antibiotic treatment” and sometimes more severe treatments like surgery. An apparently rare physical consequence is synovitis of the wrists, which, as it says on the internet, is the inflammation of a membrane in the wrist called the synovial, and is similar to carpel tunnel and tendonitis. Other physical consequences are not listed.

Excoriation disorder is usually accompanied by other mental disorders, such as obsessive compulsive disorder, trichotillomania and major depressive disorder. This is called co-morbidity.

Body-Focused Repetitive Behaviours

What is in the DSM-5 about BFRBs is very brief. In fact, it’s only a paragraph in a subsection of the Obsessive Compulsive and Related Disorders called “Other Specified Related Disorders,” which is essentially saying that these issues don’t have full-fledged categorization yet, but they’re on the radar of medical researchers.

Nail, cheek and lip biting are all mentioned as examples of these fledgling BFRBs, along with how these behaviours would differ from everyday habits. “These symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning,” meaning that these aren’t throwaway instances, but frequent ones that the individual has a difficult time stopping. The only other specification the DSM-5 gives is to say these BFRBs are not inclusive in “stereotypic movement disorder, or non-suicidal self-injury.”

This page uses information cited directly from the Disagnostic and Statistical Manual of Mental Disorders, fifth edition, published in 2013.